Trimble: Coordination key to care transformation

Physicians don’t need to change the entire system, but they play a heavy part in building a better system in their particular clinic, hospital or medical domain, he told Clinical Innovation + Technology.

Trimble is on the faculty at the Tuck School of Business at Dartmouth College and The Dartmouth Center for Health Care Delivery Science. He has been at Dartmouth College for 15 years, originally focusing on the general management challenges associated with innovation in any industry. In 2011, he joined the new research center at Dartmouth focused on innovation in healthcare.

“There’s more there than I realized at first,” he said, referring to the process of applying innovation in other industries to the field of healthcare. “It’s been a pretty tough challenge to adapt what I learned in the past.”

Healthcare differs from other industries in many ways, one of which is the way incentives have affected innovation. The ideas and benefits of care coordination, for example, have been around for a long time, but they have been “essentially encaged by our payment models. They are all money losers under fee-for-service, even though they are great for patients and for the system.”

This has led to straightforward innovation being held in check for decades. “There is a lot of great work to be done that is not high-tech, futuristic or based on breakthrough principles—it’s based on stuff that’s been around forever. The most important thing to do to unleash innovation is to move to accountable care or value-based payment. The great news is it’s happening and it’s by far the biggest reason I feel optimistic about the future of U.S. healthcare.”

Quality improvements used by other industries, such as Lean management and Six Sigma, are intended to be innovation programs every employee can be involved in, Trimble said. “The power of that is companies can leverage the full intellect and insight of every brain in the organization.” In healthcare, however, there are very limited resources available to employees and just “a tiny sliver of slack time in people’s schedules. People in healthcare already are working overtime.”

The community can make bigger leaps by commissioning full-time teams to redesign care and deliver better care for select patient populations rather than push tools and technologies, Trimble argued.

Such teams are rare in healthcare, he said, because they tend to lose money under the fee-for-service business model plus they just aren’t familiar to workers. In his book, he shares the example of a new clinic designed specifically to serve the needs of children with complex conditions and their families.

The clinic is jointly operated by the University of Utah and Intermountain Healthcare. The patients have intensive and expensive needs such as genetic abnormalities or spine or brain injuries. “The system tends to fall short for these families for lack of good care planning and care coordination. Even though the families, by and large, are very committed to taking good care of their children, they’re simply overwhelmed.”

One physician, Nancy Murphy, MD, started with a team of four who were dedicated to the clinic full-time. “Because of the flexibility that implies, they could truly rethink care from scratch,” said Trimble. The team designed a process in which families come in for 60- to 90-minute appointments and typically see all four members of the team plus specialists. The team has a huddle about each patient to share observations and recommendations and then go back for a final conversation with the family. Because families dealing with trauma often have questions later, they keep one-third of the schedule open for ongoing communication with families and specialists.

Just by word of mouth, the clinic got all the patients it could handle. Those patients were in the hospital and emergency department less often—25 percent and 14 percent, respectively. Costs to the system were cut by more than 10 percent. It’s very rare for a new device or drug to deliver a “double whammy” like that, he said. However, the clinic was a money loser under fee-for-service and only survived thanks to the dedicated support of the chief medical officer. With accountable care contracts, it’s now sustainable.

“There’s nothing complicated going on here. It’s nothing more than care planning and care coordination. It’s not high tech or disruptive yet the results are spectacular.”